NCLEX-PN
NCLEX PN Prep Questions Questions
Extract:
Question 1 of 5
Continuous bladder irrigation is prescribed for an adult who had bladder surgery; 1000 mL of irrigating solution was instilled in the last eight hours. The amount of drainage in the urine drainage bag for the last eight hours is 1700 mL. How much is the client's urine output for the last eight hours?
Correct Answer: B
Rationale: Urine output is calculated by subtracting instilled irrigation fluid (1000 mL) from total drainage (1700 mL), yielding 700 mL of actual urine.
Question 2 of 5
A client with ascites due to cirrhosis has increasing shortness of breath and abdominal pain and is scheduled for paracentesis. Which of the following nursing actions should be implemented prior to the procedure? Select all that apply.
Correct Answer: A,D,E
Rationale: Informed consent ensures understanding, emptying the bladder prevents injury during needle insertion, and baseline vital signs/weight monitor fluid shifts. Reverse Trendelenburg is inappropriate; upright positioning is typical. NPO status isn't required for paracentesis.
Question 3 of 5
A 57 year-old male client has a hemoglobin of 10 mg/dl and a hematocrit of 32%. What would be the most appropriate follow-up by the home care nurse?
Correct Answer: A
Rationale: Ask the client if he has noticed any bleeding or dark stools. These values indicate mild anemia, and the first step is to assess for potential sources of blood loss.
Question 4 of 5
The nurse is caring for a client at 15 weeks gestation who has hyperemesis gravidarum. Which of the following findings would be consistent with the condition?
Correct Answer: B
Rationale: Hyperemesis gravidarum causes severe vomiting, leading to ketosis (moderate to high urine ketones) from fat breakdown. Bradycardia, hyperkalemia, and hypertension are not typical; tachycardia and hypokalemia may occur.
Question 5 of 5
A nurse is caring for a client who had a vaginal birth 2 hours ago. The nurse notes that the client's perineal pad is saturated with blood 20 minutes after placing a new pad. The client's fundus is boggy, palpable above the level of the umbilicus, and deviated to the right. Which intervention should the nurse perform first?
Correct Answer: C
Rationale: A boggy, deviated fundus and heavy bleeding suggest uterine atony and possible bladder distension preventing uterine contraction. Assisting to void relieves bladder pressure, promoting uterine involution. Oxytocin follows if bleeding persists.